342700067-9-30-2021-27-AS-KHOS-C7ZJ5T-20211021064517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700067
Report Date: 09/29/2021
Date Signed: 09/30/2021 07:28:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2021 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20210611164204

FACILITY NAME:	HOSPITALITY HOUSE		FACILITY NUMBER:	342700067
ADMINISTRATOR:	SONYA SMITH		FACILITY TYPE:	740
ADDRESS:	5400 KIERNAN AVENUE		TELEPHONE:	(209) 543-9275
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 51	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	03:15 AM
MET WITH:	Lorraine Padill, Administrator		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Admission agreement was signed without authorization from the resident's authorized representative.
Facility staff did not administer medication as prescribed
Facility staff did not adhere to the terms and conditions of the admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt arrived at the faciltiy unnanounced to deliver complaint findings on the above allegations. LPA met with Administrator Lorraine Padilla and explaine the purpose of todays visit.

Regarding the allegations that the Admissions agreement was signed without authorization from the residents authorized representative after reviewing documents and speaking with the resident who says there is no power of attorney in place. All documents were signed by resident and no power of attorney has been submitted to licensing or the facility. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210611164204

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOSPITALITY HOUSE	FACILITY NUMBER: 342700067
	VISIT DATE: 09/29/2021

NARRATIVE

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Regarding the allegation that the facility staff did not administer medications as provided. LPA reviewed medication lists along with electronic medication administration records. The records show all residents medications were logged and given to resident daily. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation that the facility staff did not adhere to the terms and conditions of the admissions agreement. LPA confirmed over the phone with National Home Health that they did visit the facility to assist resident with physical therapy. There was also a nurse sent by National Home Health to the facility by home health to assist in residents care. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There were no deficiencies cited during today's visit per California Code of Regulations, Title 22. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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